August 24, 2012

You've heard of willful blindness, where someone doesn't see what they don't want to see. Something is happening that you approve of, and you don't want to have to do something about it, so you keep yourself in a state of unseeing to avoid responsibility. The term "willful blindness" is used to assign responsibility.

Consider willful anosmia — not smelling what you don't want to smell. ("Anosmia" is the word that corresponds to blindness in the olfactory realm.) I'm looking at the case of Donald Harvey, a hospital orderly who — over a period of 24 years — killed something like 70 patients, mostly poisoning them with cyanide. Murder was finally recognized by a pathologist who smelled cyanide during an autopsy.

Once caught, Harvey began confessing:

[A]n unrepentant Harvey described details of his murders matter of factly – “Like he would tell you that he had gone out to get a sandwich for lunch.”...

“Some of those (patients) might have lasted a few more hours, or a few more days, but they were all going to die. I know you think I played God, and I did,” Harvey said. “I believe God has forgiven me.”...

In all those years — all those other murders — why did no one else smell the cyanide? Harvey chose patients who were expected to die and thus absorbing hospital resources for no particularly useful end. The orderly's euthanasia, once known, would have to be stopped. But this activity that would be condemned if discovered benefited the institution that failed to discover it.

Was there willful anosmia?

IN THE COMMENTS: billo said:

I'm a forensic pathologist. The ability to smell cyanide is genetically determined, and most people, in fact, cannot smell it or smell it as an unrecognizeable odor (some say it smells more like bleach than "bitter almonds").

When I was in training, an unsuspected cyanide case came in -- none of the people on the case were perceivers, and we all became a bit ill from the outgassing. After awhile one of the people who could perceive cyanide came in and recognized it. Our Chief then had everybody in the office come in and take a whiff so we would know who could and could not smell it. That way, we could call the right people into the room if we suspected it the next time.

So, billo, what does this tell us about the hospital missing so many murders by cyanide all those years?

I'm a forensic pathologist. The ability to smell cyanide is genetically determined, and most people, in fact, cannot smell it or smell it as an unrecognizeable odor (some say it smells more like bleach than "bitter almonds").

When I was in training, an unsuspected cyanide case came in -- none of the people on the case were perceivers, and we all became a bit ill from the outgassing. After awhile one of the people who could perceive cyanide came in and recognized it. Our Chief then had everybody in the office come in and take a whiff so we would know who could and could not smell it. That way, we could call the right people into the room if we suspected it the next time.

Maybe that last body reeked of cyanide so bad that even the grave digger could have smelled it eventually. It just couldn't be covered up up anymore.Kind of like the wife of a cheating politician, who allowed his behavior until the press caught wind of it. Then she had to divorce him.

Harvey chose patients who were expected to die and thus absorbing hospital resources for no particularly useful end

I don't see the evidence for this motivation. In order to tie his actions to "hospital resources" you need to show the patients continued lives were detrimental to the hosptital. I see no evidence this is true since the hospital was presumably being paid. The beneficiaries of his acts were the insurance carriers and medicare.

He may have thought he was doing this to end the patients suffering. More likely he enjoyed killing and thought killing the near-dead would result in less scrutiny. But one of the benefits of American medical structure is that those in charge of your care don't benefit from your death.

He didn't always use cyanide. Sometimes he used arsenic. How many of the victimes were autopsied? The article doesn't say. I'd be surprised if every person in a hospital and expected to die within hours or days was autopsied. Still, he killed a LOT of people before being caught.

Many people can't smell cyanide, including me. Several years ago I was running bench scale experiments on a new treatment for wastewater containing cyanide. I had to conduct the experiments in a lab hood, but I would take out the little beakers of samples and work with them outside the hood after I thought I had heated them enough to drive off any leftover free cyanide. The second day I did this, the lab manager walked in, came straight to my bench, picked up the beakers, and put them back under the hood. She said "couldn't you smell that?", and I said "what smell?". "It smells just like bitter almonds" to which I said "almonds have a smell?" Needless to say, I had to do everything under the lab hood from then on, since I could not smell cyanide at all.

Autopsies are still not performed in the case of most deaths. It is only 'suspicious or unexplained' deaths that might warrant one. If a person is extremely ill and has a record of that illness and a doctor's record of it, no autopsy is performed.

When my mother died after a decade of declining health, a phone call from the policeman -- who arrived to see what was going on following my father's 911 call -- to her primary care doctor was sufficient to permit the release of her body to the undertakers. She was cremated within three hours of her reported death.

It was well known that she would die of her illness; the only question was when.

My mother-in-law was found dead in her apartment, lying on her bed. Again, the police needed only to contact her physician who said that he would not find her having died in her sleep suspicious.

Critically ill people in hospitals don't normally get autopsied unless there's some question about the circumstances or hospital liability.

Autopsies are still not performed in the case of most deaths. It is only 'suspicious or unexplained' deaths that might warrant one. If a person is extremely ill and has a record of that illness and a doctor's record of it, no autopsy is performed.

When my mother died after a decade of declining health, a phone call from the policeman -- who arrived to see what was going on following my father's 911 call -- to her primary care doctor was sufficient to permit the release of her body to the undertakers. She was cremated within three hours of her reported death.

It was well known that she would die of her illness; the only question was when.

My mother-in-law was found dead in her apartment, lying on her bed. Again, the police needed only to contact her physician who said that he would not find her having died in her sleep suspicious.

Critically ill people in hospitals don't normally get autopsied unless there's some question about the circumstances or hospital liability.

"So, billo, what does this tell us about the hospital missing so many murders by cyanide all those years?"

It tells us that no one who could smell cyanide happened to examine any of the victims, and, given their reported imminent deaths, it was simply assumed they had expired, as expected, from whatever other agency had brought them to the hospital and to the point of expected near-death.

What other inference should we take?

Medical professionals are humans doing jobs of work, not gods, and, as with others in any field, they vary in their knowledge, experience, skills, talent, and aptitude for taking the uncommon view.

Dad spent the last 6 weeks of his life in a rest home with dementia. One day I visited, and the head nurse told me that my father had fallen. The nurse went on to tell me that he would be dead in the next couple of days.

One of the few things I remember from college chemistry was a comparison of cyanide and Hydrogen Sulfide.

Both are roughly equal in toxicity, but death from Hydrogen Sulfide is pretty rare even though it is far more common in the environment than cyanide. The reason is that Humans can detect Hydrogen Sulfide at concentrations far below fatal. The opposite is true of cyanide. What our Prof said was that for most people, a lethal dose of cyanide is not much more than the level needed to smell it.

He also indicated that every time he had smelled cyanide, the result was a raging headache. So, if students were curious about the smell, he offered to let them smell some, but at the very least, you would get a bad headache. None of the students took up his offer.

I think I've smelled cyanide; and I know I've smelled almond extract; and there's no similarity to me.

The cyanide was in the form of sodium cyanide crystals, in a big barrel, in an electroplating operation. They stunk of body-odor, a rancid bitter stink. I'd have to bend into the barrel to scoop up crystals to add to the plating solution, and if I got a good noseful of it, I'd have to blow my nose and spit a few times to get rid of the stink/taste.

I can remember that smell now, 27 years later, just typing this.

Maybe that wasn't gaseous cyanide (CN) but instead airborne tiny dust particles of NaCN. But I think it's more likely that it was HCN (hydrogen cyanide) given off because of moisture in the air that reached the briquettes of NaCN.

My only safety gear in this plating operation, by the way, was a pair of rubber gloves, with holes in them. I'd frequently get the acidic plating solution inside the gloves.

dbp, Hydrogen Sulfide is an extremely dangerous gas, and accounts for numerous fatalities. According to US Occupational Safety and Health Administration (OSHA) investigation records for the period 1984 to 1994 for mention of hazardous substance 1480 (hydrogen sulfide), there were 80 fatalities from hydrogen sulfide in 57 incidents, with 19 fatalities and 36 injuries among coworkers attempting to rescue fallen workers.

Although H2S has an unpleasant "rotten eggs" odor, it can desensitize ones sense of smell, giving a false sense of safety. A typical accident might involve a worker inspecting a culvert or spillway with stagnant water present in which bacteria had generated the gas.

A phosphate mine where I worked required a special "enclosed space entry permit" for which a safety technician used an instrument to sample the air and declare it safe.

Oh, wait -- the pair of gloves wasn't our only safety gear: We also had a couple of ancient amyl nitrate poppers on a shelf over the plating apparatus. The theory was that if I started to black out from the fumes, I could snap one of those under my nose, and it would be a magic antidote to cyanide poisoning.

It is unlikely the other victims were autopsied. I ask all of the families of my patients for an autopsy and only a small percentage say yes. Most doctors don't bother asking for that reason. If these were all patients who were expected to die, it is very unlikely that they had autopsies. And, of course, your senses of taste and smell can be greatly affected by what you expect to taste or smell. Who expects to find poison in an autopsy of a terminal cancr patient?

People also see (or smell) what don't they expect to see. This is what we see a lot in our partisan politics, people believe they are right and expect to see things that will verify that. They jump on things that match what they believe and refuse to take notice of anything that might challenge it.

There are also people who can taste the difference between decaf and regular coffee and those who can't.

I did electroplating sometimes for a small machine shop and didn't smell the cyanide. This must have been before job-killing regulation. There was an acid bath and a cyanide bath, as I recall, and you dumped the parts in in some sequence.

Cyanide poisoning is not necessarily obvious. There are certain things you can look for. Because cyanide is a respiratory poison (it stops cells from using oxygen stored in red blood cells), the tissue will tend to be brighter red than normal (much like carbon monoxide poisoning). Because it is usually ingested as an acid (an alternative name for hydrogen cyanide is "Prussic acid"), it can erode tissues, resulting in gastric erosions if swallowed or erosion of the skin if the victim lays in emesis. And, of course, if one can perceive it, it can smell.

However, there are problems. The first problem is that none of these are necessarily present in cases where doses are not great. The case where I got sick was one in which the victim drank a large quantity. If one ingests "just enough," then none of these may be obvious, and outgassing may not be prominent.

But the *biggest* problem is that you have to look for it. In order to look for it, you have to do an autopsy. In order to do an autopsy, you either have to get permission from the family for a hospital autopsy, or suspect poisining in order to get a Medical Examiner autopsy.

The rate of autopsies in cases where there is a presumed natural cause of death is dismal in the United States. Fifty years ago, it was around 50%, at least at teaching hospitals. Now it is less than 10% at most teaching hospitals, and is almost never done at non-teaching hospitals.

Three things have contributed to this. The most important is that in the age of socialized medicine, it is not valued. Medicare and other federal programs won't pay for it. Insurance won't pay for it. Thus, it *costs* hospitals money to perform autopsies, and they aren't cheap.

The second is that there is no incentive to perform autopsies. Physicans (mistakenly) believe that modern diagnostic and imaging methods provide all they need to know. They are wrong, but that's the feeling. In addition, in today's litigious environment, why would physicians suggest to families that they do something that the family will likely find distasteful, and which might show up something that would result in liability? Many physicians feel that the risk of liability outweighs the benefits to medical science and the opportunity to learn and improve practice.

Finally, there has been a cultural shift in the United States where families are more resistant to autopsies. Part of this is the increased tendency of people to view themselves as victims of the system. Families are offended by practices that were routine years ago. They don't view autopsies as ways to find out what really happened to their loved one, but as a violation of some sort. There is a more postmodern approach to the body that is actually more medieval, with more magical thinking about postmortem processes -- and families simply are more resistant to give permission.

Adding these together, it is no surprise at all that deaths of people with natural disease and who had risk factors for sudden death were simply signed out as deaths due to those natural processes. Society doesn't want to know any differently. Don't blame the hospital. Blame the lawyers, the third party payers, and the development of a society in which everybody wants to find something to be offended at.